Subject(s)
Aneurysm, Infected/diagnostic imaging , Aphasia/etiology , Embolic Stroke/diagnosis , Endocarditis, Bacterial/diagnosis , Fever of Unknown Origin/etiology , Gram-Positive Bacterial Infections/diagnosis , Leg , Pain/etiology , Aneurysm, Infected/surgery , Anticoagulants/therapeutic use , Computed Tomography Angiography , Diagnosis, Differential , Echocardiography , Enterococcus faecalis , Humans , Magnetic Resonance Imaging , Male , Middle Aged , Ultrasonography, Doppler, Color , Veins/diagnostic imaging , Veins/surgery , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/drug therapyABSTRACT
Concomitant coronary artery disease (CAD) is highly prevalent among patients with severe aortic stenosis (AS). Historically, surgical aortic valve replacement with coronary artery bypass grafting was the only treatment option for patients with severe AS and significant CAD. The rapid expansion of transcatheter aortic valve replacement has led to significant paradigm shifts in the treatment of severe AS and has raised new questions regarding the optimal management of CAD in these patients. We review the evidence regarding management of concomitant CAD in severe AS patients, specifically focusing on issues surrounding transcatheter aortic valve replacement. In the absence of robust evidence supporting specific treatment strategies, decisions regarding coronary revascularization in severe AS should be individualized and made within the context of a multidisciplinary heart team.
Subject(s)
Aortic Valve Stenosis/surgery , Coronary Artery Disease/surgery , Myocardial Revascularization/methods , Transcatheter Aortic Valve Replacement/methods , Aortic Valve Stenosis/complications , Coronary Artery Disease/complications , HumansABSTRACT
BACKGROUND: The influence of coronary artery disease (CAD) on clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR) is still controversial. We sought to evaluate the impact of CAD severity as measured by the SYNTAX score (SS) on patients undergoing TAVR. METHODS AND RESULTS: A total of 377 patients who underwent TAVR in 2 high-volume centers in North America were included in our retrospective analysis. A blinded angiographic core laboratory calculated the SS on all available coronary angiograms with the use of quantitative coronary analysis. Patients were stratified into 4 groups: (1) no CAD (SS=0); (2) low SS (SS between 1 and 22); (3) intermediate SS (SS between 23 and 32); and (4) high SS (SS ≥33). Patients who had undergone percutaneous coronary intervention within 6 months prior to TAVR were separated into 2 categories based on their residual SS (<8 and ≥8). Patients with previous coronary artery bypass grafting (CABG) were divided into 2 groups: (1) low CABG SS and (2) high CABG SS. The primary end point was a composite of all-cause mortality, myocardial infarction, and stroke. At 30 days and 1 year, both the presence and the severity of CAD had no impact on the rate of the combined primary end point and on all-cause mortality, cardiovascular mortality, and myocardial infarction. Patients with less complete revascularization (residual SS ≥8 versus residual SS <8 and low CABG SS versus high CABG SS, had similar rates of the combined primary end point, all-cause mortality, cardiovascular mortality, MI, and stroke, at both 30 days and 1 year. CONCLUSIONS: In our core laboratory-validated study, neither the severity of CAD nor completeness of revascularization after percutaneous coronary intervention or CABG were associated with clinical outcomes after TAVR, at both 30 days and 1 year.
